From the Guidelines
The best intervention to improve survival in this patient is option D, adding eplerenone. This 69-year-old female has heart failure with reduced ejection fraction (HFrEF) as evidenced by her left ventricular ejection fraction of 32% and symptoms of exertional dyspnea (difficulty walking up stairs). Eplerenone, a mineralocorticoid receptor antagonist (MRA), has been shown in clinical trials to reduce mortality in patients with HFrEF, as recommended by the 2013 ACCF/AHA guideline for the management of heart failure 1. It works by blocking aldosterone receptors, which helps reduce sodium retention, myocardial fibrosis, and adverse cardiac remodeling. The starting dose would typically be 25 mg daily, with monitoring of potassium and renal function.
While the patient is already on several appropriate medications for her condition (including an ACE inhibitor/ARB, beta-blocker, diuretic, and statin), the addition of an MRA like eplerenone represents guideline-directed medical therapy that has demonstrated mortality benefit. The other options (increasing Lasix, adding amlodipine, adding digoxin, or adding ivabradine/Corlanor) have not consistently shown the same level of mortality benefit in patients with HFrEF and would not be the first choice for improving survival in this clinical scenario. According to the 2019 ACC/AHA versus ESC guidelines on heart failure, the use of MRAs is recommended in patients with NYHA functional class II to IV HF who have LVEF ≤35% to reduce morbidity and mortality 1.
Key points to consider in this patient's management include:
- The patient's left ventricular ejection fraction of 32% and symptoms of exertional dyspnea indicate HFrEF
- The patient is already on several appropriate medications, but the addition of an MRA like eplerenone is recommended to reduce mortality
- Monitoring of potassium and renal function is necessary when starting eplerenone
- The other options (increasing Lasix, adding amlodipine, adding digoxin, or adding ivabradine/Corlanor) are not the first choice for improving survival in this clinical scenario.
From the FDA Drug Label
The eplerenone post-acute myocardial infarction heart failure efficacy and survival study (EPHESUS) was a multinational, multicenter, double-blind, randomized, placebo-controlled study in patients clinically stable 3 to 14 days after an acute MI with LV dysfunction (as measured by left ventricular ejection fraction [LVEF] ≤40%) and either diabetes or clinical evidence of HF (pulmonary congestion by exam or chest x-ray or S 3). For the co-primary endpoint for death from any cause, there were 478 deaths in the eplerenone group (14.4%) and 554 deaths in the placebo group (16.7%). The risk of death with eplerenone was reduced by 15% [hazard ratio equal to 0.85 (95% confidence interval 0.75 to 0.96; p = 0. 008 by log rank test)].
The intervention that has been shown to improve survival in patients such as the one described is adding Eplerenone. This is based on the results of the EPHESUS study, which demonstrated a 15% reduction in the risk of death from any cause in patients with heart failure post-myocardial infarction who received eplerenone compared to those who received placebo 2.
From the Research
Patient Profile and Current Condition
The patient is a 69-year-old female with a history of chronic hypertension and previous myocardial infarction (MI), presenting for follow-up six weeks after hospitalization for chest pain. Her current medications include aspirin, atorvastatin, Lasix, Lepri, and Toprol XL. She reports difficulty walking up a single flight of stairs despite feeling comfortable at rest.
Echocardiogram and EKG Findings
- Echocardiogram shows a left ventricular ejection fraction (LVEF) of 32%.
- EKG reveals sinus rhythm with a heart rate of 52 beats per minute, multiple occasional premature ventricular contractions (PVCs), and a QRS interval of 0.1 seconds.
Intervention Options
Considering the patient's profile and current condition, the following intervention options are provided:
- Option A: Increase Lasix dose
- Option B: Add a lot of pain medication (not specified)
- Option C: Add digoxin
- Option D: Add eplerenone
- Option E: Add Corlanor (ivabradine)
Evidence-Based Recommendations
Based on the provided studies:
- Reducing Heart Rate: Studies 3, 4 suggest that reducing heart rate can improve outcomes in patients with heart failure and reduced ejection fraction (HFrEF). Ivabradine, which specifically reduces heart rate without affecting blood pressure or contractility, has been shown to improve survival and reduce hospitalizations in such patients.
- Digoxin: The study 3 found that commencing therapy with digoxin or ivabradine is associated with an improved prognosis in patients with HFrEF, suggesting that digoxin could be a beneficial addition for this patient.
- Guideline-Directed Medical Treatment: The management of HFrEF involves guideline-directed medical therapy, including beta-blockers, ACE inhibitors or ARBs, and possibly aldosterone antagonists like eplerenone, as outlined in 5 and 6.
- Patient Profiles and Treatment: The study 7 emphasizes the importance of tailoring treatments to individual patient profiles, considering factors like renal function, systolic blood pressure, heart rate, and presence of atrial fibrillation.
Potential Interventions
Given the evidence:
- Option C (Add digoxin) and Option E (Add Corlanor) could be considered to improve survival and reduce symptoms, as they directly address heart rate reduction, which is beneficial in HFrEF patients.
- Option D (Add eplerenone) might be considered for its aldosterone antagonist effects, which can be beneficial in HFrEF patients, especially if there's evidence of volume overload or hypertension that's not adequately controlled.
- The other options (A and B) are less directly supported by the provided evidence for improving survival in the context of HFrEF.